2.0 Analysis 2.1 Personnel Factors on the SEALNES The navigation team on the SEALNES had been advised by the VTC MTR of two radar targets, one off the Cap light and a second approaching the Lions Gate Bridge outbound. The navigation team would naturally try to account for the two targets in terms of their current understanding of the situation6. Two tugs were expected to assist in berthing the vessel. After the two tugs were identified, the location of the outbound target, ahead of the SEALNES, was not determined. It is considered that the most probable explanation for the MR. FISSION not being detected by the SEALNES is that the navigation team equated the two targets with the tugs they were expecting. With any potential danger from the two reported radar targets now apparently discounted, the navigation team continued preparing for the berthing operation without perceiving a need to validate or confirm the conclusion that the target which had been reported in a position ahead of the SEALNES had been one of the tugs. No information was brought to the attention of the navigation team from 6 ibid, p. 59. on board or from other sources, such as the VTS or the MR. FISSION, that would have forced them to re-evaluate the situation. The SEALNES continued toward her berth unaware of the vessel in her path. 2.2 Conduct of the MR. FISSION The operator's original intentions showed that he was aware of the danger from traffic in the main channel, but his final decision to keep to the port side of the channel, even with the intent of keeping close to the shore, had the effect of putting his vessel close to the lane used by inbound traffic. In the event, when the main engine subsequently broke down, the tidal stream carried the MR. FISSION outward in the main inbound lane. Although the vessel was not participating in the VTS traffic scheme, good seamanship practice suggests that it would have been prudent, at that point, to have advised the VTC by radio of the situation so that some warning could be given as to the whereabouts of the MR. FISSION. The most probable explanation for the SEALNES not being observed by the MR. FISSION is that the operator was distracted from navigational duties, such as maintaining a proper look-out, by the problem with the main engine. 2.3 Vessel Traffic Services (VTS) Traffic Advisory It would have been useful for the MTR to have further monitored the unidentified target which represented the MR. FISSION. When the traffic report was given to the SEALNES after passing buoy QB, the target was on the wrong side of the channel. The VTC radar video record showed that it shortly became evident that the target had stopped in the channel, a situation which warranted a further advisory to the SEALNES. 3.0 Conclusions 3.1 Findings The MR. FISSION experienced difficulties with the main engine when about to undertake a passage of the First Narrows. The operator of the MR. FISSION elected to keep his vessel to the port side of the channel close to the south shore. A subsequent breakdown of the engine of the MR. FISSION resulted in the vessel being carried by the tidal current into the main inbound shipping lane. The inbound SEALNES had been advised by the Vessel Traffic Centre (VTC) of two unidentified targets in the First Narrows. One of the two tugs which were to assist in berthing was identified as being in one of the target locations. After the two assisting tugs were sighted, those navigating the SEALNES did not determine the location of the other target. Those on the MR. FISSION were preoccupied with the engine and did not keep a look- out or alert the VTC of their situation. The VTC Marine Traffic Regulator (MTR) did not monitor the unidentified target after giving the traffic report to the SEALNES. There was no follow-up advice from the VTC to the SEALNES regarding the unidentified target having stopped in the main channel. Neither vessel was aware of the presence of the other and they collided. The MR. FISSION was overturned in the collision and the occupants were thrown into the water. The crew members of the MR. FISSION were promptly picked up by one of the tugs in the vicinity. 3.2 Causes The SEALNES and the MR. FISSION collided because both vessels were not maintaining a proper look-out and neither vessel had determined that a risk of collision existed. 4.0 Safety Action 4.1 Action Taken 4.1.1 Navigational Skills While the crew members of the MR. FISSION were preoccupied with the engine problem, they did not keep a look-out or alert the Vessel Traffic Centre (VTC) of their situation. This behaviour may be indicative of a lack of awareness of basic seamanship and navigational skills. The Board has previously expressed concern that a lack of basic operational skills on the part of operators of small fishing vessels has contributed to the frequency and severity of marine occurrences. As a result, the Board recommended that: The Department of Transport ensure that any person required to have the conduct of a commercial fishing vessel possess the basic skills for safe navigation. In response, Transport Canada indicated that requiring certification for competency by way of traditional methods of examination is not practical for commercial fishing vessels below a specific size. However, the Canadian Coast Guard (CCG) will continue to work toward requirements which will encompass those commercial fishing vessels not traditionally requiring certification.